1164680914 NPI number — ROBERT P. BOLLING, MD, LLC

Table of content: (NPI 1164680914)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164680914 NPI number — ROBERT P. BOLLING, MD, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ROBERT P. BOLLING, MD, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1164680914
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/25/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1005
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FAYETTE
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35555-1090
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
205-748-0158
Provider Business Mailing Address Fax Number:
205-932-4159

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1035 TEMPLE AVE N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FAYETTE
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35555-1923
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
205-748-0158
Provider Business Practice Location Address Fax Number:
205-932-4159
Provider Enumeration Date:
05/29/2008

Additional Information

Authorized Official

Authorized Official Last Name:
BOLLING
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
P.
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
205-748-0158

Provider Taxonomy Codes

  • Taxonomy code: 2086S0122X , with the licence number:  24251 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 9185060 . This is a "AETNA" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 143956 . This is a "MEDICAID-WINFIELD" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 144069 . This is a "MEDICAID-FAIRHOPE" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 511-21951 . This is a "BLUE CROSS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 135596 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".




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